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Each Medical Record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.
6 Key Attributes of a Medical Record Accuracy of the medical record. The accuracy of the data refers to the correctness of the data collected. ... Accessibility of the medical record. ... Comprehensiveness of data. ... Consistency of information in the medical record. ... Timeliness of information. ... Relevancy of the medical records.
Medical Records and PHI should be stored out of sight of unauthorized individuals, and should be locked in a cabinet, room or building when not supervised or in use. Provide physical access control for offices/labs/classrooms through the following: Locked file cabinets, desks, closets or offices.
Client's Words, Clarity, Completeness, Conciseness, Chronological Order and Confidentiality.
Medical records typically consist of self-reported patient information along with doctor's notes on diagnoses, care and treatments. But there's so much more to it. We want to help people understand why medical records are important.
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People also ask

What does recordkeeping mean? Recordkeeping is the act of keeping track of the history of a person's or organization's activities, generally by creating and storing consistent, formal records.
The Six C's of charting.
First one is that it helps in proper evaluation of the patient and to plan treatment protocol. Second is that the legal system relies mainly on documentary evidence in cases of medical negligence. Therefore, medical records should be properly written and preserved to serve the interest of doctor as well as his patient.
Types of records Correspondence records. Correspondence records may be created inside the office or may be received from outside the office. ... Accounting records. The records relating to financial transactions are known as financial records. ... Legal records. ... Personnel records. ... Progress records. ... Miscellaneous records.
Archive and destruction can be done at two separate stages. You may archive (or thin out) paper records for a transition period and record the archived records in the log. When the records meet retention periods (and the practice makes appropriate decisions) the archive log can be used again as destruction log.

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